Basic Information
| Provider Information | |||||||||
| NPI: | 1790745644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERVIEW HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROWN COUNTY HEALTH & LIVING COMMUNITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2759 E COVENANTER DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474015454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123322265 | ||||||||
| FaxNumber: | 8123340853 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WILLOW ST | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474487013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129886666 | ||||||||
| FaxNumber: | 8129886668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8123322265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 000479-1 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100290880B | 05 | IN | MEDICAID |